(a) Except where there is an agreement to the contrary between a third-party payer and the health care provider, as defined in section 19a-17b, all health care providers shall submit all third-party claims for payment on the current standard Health Care Financing Administration Fifteen Hundred (HCFA1500) health insurance claim form or its successor, or in the case of a hospital or other health care institution, a Health Care Financing Administration UB-92 health insurance claim form or its successor, or in accordance with other forms which may be prescribed by the Insurance Commissioner.
(b) For any claim submitted to an insurer on the current standard Health Care Financing Administration Fifteen Hundred health insurance claim form or its successor, if the following information is completed and received by the insurer, the claim may not be deemed to be deficient in the information needed for filing a claim for processing pursuant to subparagraph (B) of subdivision (15) of section 38a-816.
| Item Number | Item Description |
| 1a | Insured's identification number |
| 2 | Patient's name |
| 3 | Patient's birth date and sex |
| 4 | Insured's name |
| 10a | Patient's condition - employment |
| 10b | Patient's condition - auto accident |
| 10c | Patient's condition - other accident |
| 11 | Insured's policy group number |
| (if provided on identification card) | |
| 11d | Is there another health benefit plan? |
| 17a | Identification number of referring physician or |
| advanced practice registered nurse | |
| (if required by insurer) | |
| 21 | Diagnosis |
| 24A | Dates of service |
| 24B | Place of service |
| 24D | Procedures, services or supplies |
| 24E | Diagnosis code |
| 24F | Charges |
| 25 | Federal tax identification number |
| 28 | Total charge |
| 31 | Signature of physician, advanced practice |
| registered nurse or supplier with date | |
| 33 | Physician's, advanced practice registered nurse's |
| or supplier's billing name, | |
| address, zip code & telephone number |
(c) For any claim submitted to an insurer on the current standard Health Care Financing Administration UB-92 health insurance claim form or its successor, if the following information is completed and received by the insurer, the claim may not be deemed to be deficient in the information needed for filing a claim for processing pursuant to subparagraph (B) of subdivision (15) of section 38a-816.
| Item Number | Item Description |
| 1 | Provider name and address |
| 5 | Federal tax identification number |
| 6 | Statement covers period |
| 12 | Patient name |
| 14 | Patient's birth date |
| 15 | Patient's sex |
| 17 | Admission date |
| 18 | Admission hour |
| 19 | Type of admission |
| 21 | Discharge hour |
| 42 | Revenue codes |
| 43 | Revenue description |
| 44 | HCPCS/CPT4 codes |
| 45 | Service date |
| 46 | Service units |
| 47 | Total charges by revenue code |
| 50 | Payer identification |
| 51 | Provider number |
| 58 | Insured's name |
| 60 | Patient's identification number |
| (policy number and/or | |
| Social Security number) | |
| 62 | Insurance group number |
| (if on identification card) | |
| 67 | Principal diagnosis code |
| 76 | Admitting diagnosis code |
| 80 | Principle procedure code and date |
| 81 | Other procedures code and date |
| 82 | The identification number of |
| the attending physician or advanced | |
| practice registered nurse |
(d) The commissioner may adopt regulations, in accordance with chapter 54, to implement the provisions of this section.
(P.A. 93-109; P.A. 03-57, S. 2; P.A. 12-197, S. 41.)
History: P.A. 03-57 substituted “Health Care Financing Administration UB-92 health insurance claim form” for “UB-82” in Subsec. (a), added new Subsecs. (b) and (c) re information on HCFA1500 claim form and UB-92 claim form, respectively, redesignated existing Subsec. (b) as Subsec. (d) and made technical changes therein; P.A. 12-197 amended Subsec. (b) by adding references to advanced practice registered nurse in items 17a, 31 and 33 and amended Subsec. (c) by adding reference to advanced practice registered nurse and making a technical change in item 82.